Parajuli Parmatma, Ali Saeed, Singh Shubhechchha, Guan Jian, Manoucheri Manoucher
Internal Medicine, AdventHealth Orlando, Orlando, USA.
Medicine, Florida Hospital, Orlando, USA.
Cureus. 2020 Jan 14;12(1):e6653. doi: 10.7759/cureus.6653.
Background and aims The Accreditation Council for Graduate Medical Education (ACGME) mandates that Internal Medicine residents shall place all the orders for their patients. The purpose of this rule is to assure comprehensive knowledge of patient information and direct involvement in decision-making. However, there is a general perception that a large proportion of orders for patients taken care of by the residents are being written by consultants or other providers. The objective of the study was to determine the proportion of routine orders placed by Internal Medicine residents in comparison to consultants/subspecialty providers for patients under the care of the Internal Medicine Residency Service (IMRS). Material and methods All the orders on patients admitted to the IMRS at AdventHealth Orlando from July 9, 2017, to July 15, 2017, were documented. Of these, Emergency Department (ED) orders, "STAT/ASAP/NOW orders," "discharge by consultant" orders, and "consent for procedure" orders were excluded. The main outcome measure was the proportion of orders placed by Internal Medicine residents as compared to consultants and all other providers. Results A total of 6471 orders placed on 90 patients admitted to the IMRS and with at least one consultant were included in the study. Of them, 96.8% of all orders were placed by Internal Medicine residents. Only 3.1% of all orders were placed by consultants and other providers. Of them, the majority of the orders were specialty-specific orders and were appropriate. Only 1.1% of all orders were "routine" orders placed inappropriately by consultants and other providers. A total of 121 consultations were made, and there were no new consultations initiated by consultants and other providers during the study period. Conclusion The vast majority of orders for patients taken care of by the IMRS were placed by the Internal Medicine residents themselves. Only a very small proportion of the orders were placed by consultants and other providers in this limited timeframe study. The findings are consistent with the ACGME mandate that residents write all orders for patients under their care except in special circumstances.
背景与目的 毕业后医学教育认证委员会（ACGME）规定，内科住院医师应为其负责的患者下达所有医嘱。该规定的目的是确保全面了解患者信息并直接参与决策。然而，人们普遍认为，住院医师负责照料的患者的大部分医嘱是由会诊医生或其他医疗人员开具的。本研究的目的是确定在内科住院医师服务（IMRS）所照料的患者中，内科住院医师开具的常规医嘱与会诊医生/专科医疗人员开具的医嘱的比例。
材料与方法 记录了2017年7月9日至2017年7月15日期间在奥兰多健康 AdventHealth医院IMRS住院的患者的所有医嘱。其中，排除了急诊科（ED）医嘱、“立即/尽快/现在医嘱”、“会诊医生下达的出院医嘱”以及“手术同意书医嘱”。主要观察指标是内科住院医师与会诊医生及所有其他医疗人员开具的医嘱比例。
结果 本研究纳入了90名入住IMRS且至少有一名会诊医生的患者所下达的总共6471条医嘱。其中，96.8%的医嘱由内科住院医师开具。会诊医生和其他医疗人员仅开具了3.1%的医嘱。其中，大多数医嘱是特定专科医嘱且是恰当的。会诊医生和其他医疗人员仅开具了1.1%的不恰当“常规”医嘱。总共进行了121次会诊，在研究期间会诊医生和其他医疗人员未发起新的会诊。
结论 在本有限时间框架研究中，IMRS所照料患者中的绝大多数医嘱是由内科住院医师自己开具的。会诊医生和其他医疗人员仅开具了极小比例的医嘱。这些发现与ACGME的规定一致，即住院医师应为其照料的患者开具所有医嘱，特殊情况除外。
